Macular hole after laser in situ keratomileusis and photorefractive keratectomy

doi:10.1016/S0002-9394(00)00855-2

American Journal of Ophthalmology

Volume 131, Issue 5, May 2001, Pages 666-667

Presented in part at the Vitreous Society 17th Annual Meeting, Rome, Italy, September 1999.

https://doi.org/10.1016/S0002-9394(00)00855-2 Get rights and content

Abstract

PURPOSE: To describe three myopic patients who developed unilateral macular hole after undergoing bilateral laser in situ keratomileusis or photorefractive keratectomy.

METHODS: Case reports.

RESULTS: Three eyes of three myopic patients developed a macular hole in one eye after bilateral laser in situ keratomileusis or photorefractive keratectomy. The macular hole formed between 4 to 7 weeks after laser in situ keratomileusis in case 1 (a 48-year-old woman), and within 2 months after laser in situ keratomileusis in case 2 (a 36-year-old woman). In case 3 (a 45-year-old man), the macular hole was found 9 months after photorefractive keratectomy. A vitrectomy closed the macular hole of case 1 with final best-corrected visual acuity of 20/25 and case 2 with 20/30, whereas case 3 declined further surgery.

CONCLUSION: A macular hole may develop in myopic eyes after laser in situ keratomileusis or photorefractive keratectomy. Vitreoretinal interface changes may play a role.

Section snippets

Case 1

A 48-year-old white woman with −6.5 diopters of myopia underwent bilateral laser in situ keratomileusis in September 1997. The preoperative best-corrected visual acuity was 20/20, and the macula was normal in both eyes. The postoperative best-corrected visual acuity was 20/20 in both eyes. Four weeks after surgery, she noted the onset of blurred vision involving her right eye (RE). Examination at 7 weeks after surgery showed a stage 2 macular hole associated with a best-corrected visual acuity

Case 2

A 36-year-old white woman with −8.5 diopters of myopia underwent bilateral laser in situ keratomileusis in November 1998. Postlaser in situ keratomileusis visual acuity was 20/20 for each eye. Mild central visual blurring of the right eye occurred 1 month later. The retinal examination 2 months after laser in situ keratomileusis revealed a stage 2 macular microhole associated with a best-corrected visual acuity of RE: 20/70. A faint hyperfluorescent spot corresponding to the microhole was seen

Case 3

A 45-year-old white man with −7.0 diopters of myopia and a best-corrected visual acuity of 20/20 in both eyes underwent bilateral photorefractive keratectomy in January 1998. No complications were encountered, and the macula was normal in both eyes. Nine months after surgery, a stage 2 macular hole was noted, and the best-corrected visual acuity dropped to RE: 20/40. No additional surgery was performed.

Although laser in situ keratomileusis and photorefractive keratectomy are extraocular

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One case of bilateral cystoid macular edema and retinal phlebitis has been published, although an association remains unclear.36 In 2001, Chan et al published three cases of macular holes occurring 4 to 7 weeks after LASIK treatment.14 In addition to two other publications on the occurrence of a macular hole after LASIK,5,55 the largest series to date was reported by Arevalo and co-workers who described 20 cases of macular hole in 19 patients after LASIK for correction of myopia in a population of 83,938 eyes (incidence 0.02%).6,9
Laser in situ keratomileusis (LASIK) is the most common surgical procedure for treatment of refractive errors worldwide. Most of its complications are related to the refractive outcome or to corneal and anterior segment injury and wound healing. We review published posterior segment complications of LASIK, current clinical and experimental hypotheses explaining the occurrence of these events, and their management and outcome. Vitreoretinal complications after LASIK are very rare, and a cause–effect relationship between LASIK and reported posterior segment complications has not been proven.
Full-thickness macular hole after LASIK for the correction of myopia
2005, Ophthalmology
To describe 19 patients (20 eyes) who developed a macular hole (MH) after undergoing bilateral LASIK for the correction of myopia.
Noncomparative, interventional, retrospective, multicenter case series.
Nineteen patients (20 eyes) who developed an MH after bilateral LASIK for the correction of myopia at 10 institutions in Venezuela, Colombia, Puerto Rico, Spain, and the United States.
Chart review.
Macular hole development.
The MH formed between 1 to 83 months after LASIK (mean, 12.1). In 60% of cases, the MH developed ≤6 months after LASIK, and in 30% of cases it developed ≥1 year after LASIK. Eighteen of 19 (94.7%) patients were female. Mean age was 46 years (range, 25–65). All eyes were myopic (range, −0.50 to −19.75 diopters [mean, −8.9]). Posterior vitreous detachment was not present before and was documented after LASIK in 55% of eyes. A vitrectomy closed the MH on the 14 eyes that underwent surgical management, with an improvement of final best-corrected visual acuity in 13 of 14 (92.8%) patients. Our 20 eyes with a full-thickness MH after LASIK reflect an incidence of approximately 0.02% (20/83938).
An MH may infrequently develop after LASIK for the correction of myopia. Our study shows that vitreoretinal surgery can be successful in restoring vision for most myopic eyes with an MH after LASIK. Vitreoretinal interface changes may play a role in MH formation after LASIK for the correction of myopia.
Complete bilateral vitreous detachment after LASIK retreatment
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We describe a case of a 47-year-old woman who underwent bilateral laser in situ keratomileusis (LASIK) for the correction of myopia and astigmatism. Two months later a residual refractive error was present in both eyes. LASIK retreatment was decided and performed the following day. Twenty-four hours after the procedure, the patient reported myodesopsia in both eyes. Funduscopic examination revealed a complete bilateral posterior vitreous detachment confirmed by kinetic ultrasound. Visual disturbance in both eyes continued to be present after 10 months of follow-up. Sudden changes in intraocular pressure related to suction ring use might be the cause of posterior vitreous detachment in this patient.
Pathogenesis of macular holes and therapeutic implications
2004, American Journal of Ophthalmology
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Macular holes have been described in association with, or have been presumed secondary to, a multiplicity of other conditions.4 Most recently these have included accidental laser burns,44 subhyaloid hemorrhage,45 severe hypertensive retinopathy,46 proliferative diabetic retinopathy,47–49 retrobulbar needle penetration,50 Laser in situ keratomileusis and photorefractive keratectomy,51 uncomplicated phacoemulsification cataract surgery,52 optic pit,53 transpupillary thermotherapy of a choroidal melanoma,54 YAG laser capsulotomy,55,56 retinitis pigmentosa,57 branch retinal vein occlusion,58 ruptured retinal arterial miocroaneurysm,59 Alport syndrome,60 and fungal endophthalmitis.61 Studies in the early 1900s reported an even wider diversity of assocations.9
To review the literature and identify consistencies and inconsistencies in existing theories of pathogenesis and to consider some of their possible therapeutic implications.
Presentation of clinical case material with a synthesis of ideas on macular holes.
The literature of macular hole surgery is reviewed pertinent to pathogenic theories. Clinical examples of evolving macular holes shown on ocular coherence tomography are presented to illustrate issues.
The history of pathogenesis and macular holes is interesting in that, in many ways pathogenic theory has come full cycle. Initially, anteroposterior traction was thought to cause direct formation of a macular hole. Subsequently, degenerative and then tangential tractional etiologies were proposed. Current imaging studies have greatly advanced our understanding of anatomic features of full-thickness holes and early full-thickness hole conditions. These are most consistent with a focal anteroposterior traction mechanism, but some inconsistences in clinical cases suggest a role for degeneration of the inner retinal layers.
Degeneration of the inner retinal layers at the central fovea may predispose the eye to macular hole formation. What may otherwise be incidental tractional forces appear to initiate the hole. These tractional elements are oriented perpendicularly to the retinal surface, rather than tangentially. Further observations, especially with sequential observations from ocular coherence tomography, may yield further insights into the pathogenesis of macular holes as well as implications regarding the best repair techniques.
Choroidal neovascularization in phakic eyes with anterior chamber intraocular lenses to correct high myopia
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The CNV observed in 294 consecutive eyes (181 patients) implanted with a PACL for the correction of high myopia (–7.0 to −38.0 diopters) was studied. The mean follow-up was 50.6 months ± 32.8 (SD) (range 6 to 120 months).
Choroidal neovascularization occurred in 5 eyes (1.70%); 3 eyes were in women, and 2 were in men. The interval between PACL implantation and CNV was 63.2 ± 27.3 months (range 18 to 87 months). The CNV was subfoveal in 4 eyes and juxtafoveal in 1 case. The mean best spectacle-corrected visual acuity (BSCVA) after PACL implantation and before the appearance of CNV was 0.53 ± 0.18 (range 0.4 [20/50] to 0.8 [20/25]); after CNV appeared, it was 0.26 ± 0.18 (range 0.05 [20/400] to 0.5 [20/40]), a statistically significant difference (P = .001, paired Student t test). In 2 cases, the CNV was treated with photodynamic therapy (PDT); in the other 3 cases, PDT was rejected. The cumulative risk for CNV (Kaplan-Meier survival analysis) in highly myopic patients corrected by PACL implantation was 0.43% at 18 months and 5.4% at 87 months.
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Brief reportMacular hole after laser in situ keratomileusis and photorefractive keratectomy